Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Covington, The during CMS and state inspections, most recent first.
Incomplete kitchen logs and unsanitary tray service: The facility failed to keep dish machine temperature and sanitation logs current, failed to maintain refrigeration temperature logs for multiple units, and left paper towels at the handwash sink exposed outside the dispenser with visible wet finger marks. During meal service, an LPN handled the tray cart and resident food without hand sanitation, then washed her hands briefly after assisting a CNA with resident care before continuing tray delivery.
The facility failed to follow its antibiotic stewardship protocol. Review of the infection control program showed no evidence of antibiotic stewardship tracking or trending, and no documentation of education on trending infections or prevention. The IP nurse stated antibiotic stewardship had been tracked once but not continued, despite the facility policy requiring routine review of culture and sensitivity reports and tracking of antibiotic use and prescribing reasons.
Missing Informed Consent for Psychotropic Medications: The facility failed to document informed consent for psychotropic meds for multiple residents. Residents with diagnoses including depression, bipolar disorder, mania, psychosis, and dementia received antidepressants, antipsychotics, trazodone, divalproex, and Seroquel, but the records lacked consent documentation for initiation, dose increases, or medication changes. The DON stated some psychotropic consents had not been completed, and a pharmacy recommendation also noted missing consents in several charts.
Inconsistent bedtime snack service was identified when residents reported they were not receiving evening snacks, including residents with diabetes. The Administrator and DON stated snacks should be served daily and especially for diabetic residents, but an RN reported snack availability was inconsistent and sometimes staff had to buy snacks because the facility did not have them. Task records showed bedtime snacks were only documented sporadically for several residents, despite the facility policy stating nourishing snacks are available 24 hours a day.
A resident with an indwelling urinary catheter had the drainage bag resting on the bedside table leg, and the RN stated the bag should not contact areas not considered clean. During a medication pass, an RN touched his clothing and face while administering meds to four residents and did not perform hand hygiene before or after several administrations, despite the facility’s expectation for hand hygiene during med pass.
Psychotropic medication use was not supported by required documentation for three residents. One resident’s duloxetine dose was increased without the physician signing and dating the pharmacy recommendation, another resident’s quetiapine increase lacked behavior documentation and supporting psych notes, and a third resident’s divalproex GDR declination and later dose increase were not justified in the record. MARs showed every-shift behavior monitoring with no behaviors documented.
Failure to Provide Transfer Notice and Bed Hold Policy: A cognitively intact resident fell, later reported R hip pain, and was sent to the ER for a fractured R hip after x-ray results were received. The record lacked documentation that a notice of transfer or discharge and bed hold policy were provided with the hospital transfer, and the RN consultant stated a transfer packet should have accompanied the resident.
Inaccurate PASRR Screening for Resident With Psychosis Diagnosis: A resident with dementia and psychosis had a PASRR Level I completed that did not document the psychosis diagnosis, and the screening concluded no Level II PASRR was needed. The SSD stated she was unsure why the diagnosis was omitted, even though the facility policy required PASRR completion when a referral indicates possible SMI or ID.
Failure to provide and document ADL hygiene assistance affected three residents. One resident with moderate cognitive impairment was observed with untrimmed facial hair and long fingernails with debris, another cognitively intact resident with dementia reported not being shaved as requested, and a third resident with limited cognition had caked debris under her fingernails. Records lacked documentation that shaving or nail care was offered or refused, despite care plans and facility policies indicating these services should be provided with showers and as needed.
A resident with manic episode, depression, and vascular dementia had a pharmacy recommendation for routine lab monitoring related to medications requiring follow-up labs. The physician agreed and signed the recommendation, but the EHR lacked documentation that the labs were drawn and lacked an order for repeat labs, and the RN consultant confirmed the documentation could not be found.
Expired insulin pens labeled for one resident were found in a medication storage refrigerator, and an opened bottle of sodium chloride irrigation solution labeled for another resident was found in an insulin med cart. The RN consultant stated the insulin pens and irrigation solution were expired and should have been disposed of properly. The affected residents had orders for insulin therapy and Foley catheter irrigation, respectively.
A resident with a history of constipation and acute pain repeatedly requested to be sent to the hospital, but staff, including an LPN and RN, failed to assess or act on his reports despite multiple notifications from CNAs and a housekeeper. The resident's pain and requests were dismissed, and only after a family member intervened was the resident sent to the hospital, where he required operative intervention for severe fecal impaction and was diagnosed with gallbladder cancer.
A resident with a history of constipation experienced several days without a bowel movement and reported escalating pain, but staff failed to perform timely assessments, notify the physician, or document effective interventions. Despite repeated complaints and ineffective PRN medications, the resident's condition worsened until a family member intervened, resulting in hospital transfer and operative intervention for severe fecal impaction. Additional record reviews showed similar delays and inconsistencies in bowel management for other residents.
The facility failed to properly assess and safely transfer residents using mechanical lifts, resulting in a resident sustaining a right tibia fracture after falling from an improperly sized sling. Staff were not adequately trained on sling selection, and slings were ordered based only on weight, not manufacturer guidelines. Another resident was transferred without proper documentation or adherence to safety procedures, and a third resident with multiple falls did not receive updated preventive interventions. Employee files also lacked documentation of mechanical lift competency evaluations.
Staff failed to demonstrate competency in mechanical lift transfers, resulting in incidents where two residents were improperly transferred—one of whom fell and sustained a fracture. Staff were unclear on selecting the correct sling size and type, did not consistently follow safety procedures such as locking wheelchairs and lifts, and lacked adequate training on manufacturer guidelines and facility policy. These deficiencies placed all residents requiring mechanical lift transfers at risk.
A resident with severe cognitive impairment suffered a fall during a mechanical lift transfer, resulting in a right tibia fracture. Although the initial incident was reported to the family, the resident's POA was not notified of the fracture until the day after it was discovered, contrary to facility policy requiring timely notification of significant changes in condition.
The facility failed to provide adequate ADL assistance, as observed with residents having unkempt nails and facial hair, and insufficient showers. Despite care plans requiring regular grooming and hygiene, several residents were not properly attended to, with documentation showing inconsistencies in shower schedules. Staff interviews revealed a lack of awareness and adherence to the facility's ADL care policy.
A facility failed to notify a resident's representative of significant changes in condition and treatment, including incidents, transfers, and medication changes. The resident, on hospice services, had multiple instances where the Power of Attorney was not informed, contrary to facility policy. Staff interviews confirmed the expectation of notification, but documentation was lacking.
A resident with vascular dementia was transferred to a Behavioral Health Care hospital following an incident of inappropriate behavior, but the facility failed to complete and provide the necessary transfer and discharge documents to the resident's representative. The facility's policy required such documentation, but it was not followed, and the documents were not found in the resident's medical record.
A facility failed to provide bed hold documentation to a resident's representative during a hospital transfer. The resident, diagnosed with vascular dementia, was transferred to a BHC hospital after an incident of inappropriate behavior. The facility could not locate the required bed hold documents, which should have been completed and provided to the resident's representative, as per facility policy.
The facility failed to conduct timely care plan meetings for two residents, leading to a deficiency in care planning. One resident with multiple sclerosis had not had a meeting since February, and another with a history of cerebral infarction had not had a meeting since June. The Social Services Director was unaware of these lapses and did not document reasons for non-attendance or proceed with meetings without the residents or their representatives.
A facility failed to prevent a catheter bag from contacting the floor, posing an infection risk for a resident with a UTI. Additionally, discrepancies in urine output documentation for two residents with catheters were noted, potentially impacting care. Staff interviews revealed communication and documentation issues, with CNAs responsible for relaying output information to nurses, leading to inconsistencies.
A facility failed to properly label and date an opened bottle of tube feeding formula for a resident with severe cognitive impairment and multiple medical conditions. An LPN used a partially empty bottle for the resident's feeding without knowing when it was opened, violating the facility's policy. Another bottle was found labeled with the date and initials but lacked the time of opening, which the DON confirmed was necessary. The facility's policy on enteral tube feeding was not followed, increasing the risk of microbial contamination.
A facility failed to address a pharmacy recommendation for a dose reduction of Zoloft for a resident with depression and other conditions. Despite a recommendation to reduce the dose and document the resident's status, there was no response from the provider. Interviews with the DON and RNC confirmed the oversight, and the facility's policy requiring action on pharmacy recommendations was not followed.
The facility failed to maintain food safety and hygiene standards, as observed during a kitchen tour. A staff member was seen preparing food without a hair restraint covering his mustache, violating the facility's policy. Additionally, raw and cooked meats were improperly stored together, and expired food items were not discarded as required. The Dietary Manager acknowledged these lapses in adherence to the facility's policies.
The facility failed to maintain and document respiratory equipment properly for several residents. Observations showed undated and improperly stored oxygen tubing and nebulizer equipment, with some residents lacking documented orders for oxygen administration. Staff interviews confirmed that equipment should be dated and bagged weekly, but the facility's policy was undated, and staff did not adhere to it.
The facility failed to provide alternative hydration choices for residents, affecting all 81 residents who relied on the kitchen for drinks. Staff were instructed not to make coffee on the units due to temperature concerns, leading to the removal of coffee supplies and limiting residents' access to preferred drinks. The facility's hydration management policy, which required fluids to be offered at various times, was not followed, as only ice water was provided.
A resident with diabetes did not receive prescribed Sitagliptin-metformin HCL on multiple occasions due to the facility's failure to obtain the medication and notify the physician of missed doses. Interviews with staff revealed that established procedures for handling unavailable medications were not followed, leading to this deficiency.
The facility failed to report a resident's allegations of abuse and did not accurately document the investigation of bruising and a laceration. The resident was found with extensive bruising and a laceration, and the allegations were not reported to state authorities. The final report lacked detailed documentation and did not include the suspension of the CNA involved.
The facility failed to document and follow up on falls, injuries, and abuse allegations for three residents. One resident had multiple bruises and a laceration with no immediate follow-up or root cause identified. Another resident had repeated falls with incomplete documentation and follow-up. A third resident reported abuse, but the facility did not document follow-up or psychosocial support. Staff interviews revealed inconsistencies in the facility's process for assessing and documenting these incidents.
Incomplete Kitchen Logs and Unsanitary Tray Service
Penalty
Summary
The facility failed to maintain kitchen dish machine temperature and sanitation logs and refrigeration temperature logs, and failed to keep paper towels at the kitchen handwash sink in a sanitary manner. During the kitchen observation, the November and December 2025 dish machine logs lacked documentation for multiple breakfast and lunch rinse temperature and sanitation readings, and both monthly logs lacked documentation of wash temperature and all dinner meal readings for the entire month. Temperature logs for refrigeration appliances were also incomplete or missing, including no December 2025 logs for the stand-up refrigerator, missing readings on several dates for the stand-up freezer, and no logs observed for the walk-in refrigerator or walk-in freezer. A dietary aide stated she usually completed the refrigerator and freezer logs at the end of her shift and had not completed any readings yet that day, and she did not know where the logs were for several units. During the same kitchen observation, the towel dispenser by the handwash sink was empty, and a roll of towels was sitting on a table next to the sink with visible wet finger marks on the towels. The towel dispenser was reported to have been out of service for some time. In a separate meal service observation, an LPN was observed serving hall trays, touching the outside of the tray cart and delivering and cutting up resident food without hand sanitation during the tray pass process. The LPN later assisted a CNA to reposition a resident in bed and then washed her hands for less than 20 seconds before continuing to serve meal trays. The DON stated the nurse should have sanitized her hands between serving residents their meal trays.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to follow its antibiotic stewardship protocol program. During review of the infection control program with the Infection Prevention Nurse, the documentation lacked evidence of antibiotic stewardship tracking and trending, and there was no documentation of education regarding trending infections or prevention. In interview, the Infection Prevention Nurse stated that antibiotic stewardship had been tracked once but had not been continued. The facility’s policy, titled "Antibiotic Stewardship" and dated 3/14/23, stated that the Infection Preventionist monitors antibiotic utilization and discusses opportunities for improvement, and that the Infection Preventionist/designee reviews culture and sensitivity reports routinely, tracks how often and how many antibiotics are prescribed, and tracks how and why antibiotics are prescribed.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain documented informed consent for psychotropic medications for 5 of 5 residents reviewed for unnecessary medications. The report identified missing consents for antidepressants, antipsychotics, and other psychotropic medications when they were initiated and, in some cases, when doses were increased or medications were switched. The Director of Nursing stated that some informed consents for psychotropic medications had not been completed and that consents should have been obtained when the medications were initiated or increased. Resident 53 had diagnoses including major depressive disorder and unspecified psychosis, with moderate cognitive deficit noted on the quarterly MDS. The resident received duloxetine in multiple dose changes, Lexapro, Invega, and later olanzapine, but the record lacked documentation of informed consent for the antidepressant medications when they were initiated or increased. A document in the chart also indicated no informed consent was found for duloxetine. Resident 11 had diagnoses including unspecified mood disorder and bipolar disorder, with no cognitive deficit noted on the quarterly MDS. The resident received fluoxetine for depression and quetiapine for bipolar disorder, but the record lacked documentation of informed consent for the antidepressant medication and for the initiation and/or increase of the antipsychotic medication. Resident 10 had insomnia and mania, with moderate cognitive impairment on the quarterly MDS, and received trazodone and divalproex sodium; the electronic record lacked documentation that informed consent was obtained when these medications were initiated. Resident 74 had dementia, COPD, and diabetes, and the record indicated a psychotropic medication had been ordered without consent from the responsible party. The resident received sertraline at different doses and later duloxetine, and the chart included a pharmacy recommendation stating no informed consent was found for sertraline. Resident 47 had manic episode, depression, and vascular dementia, with severe cognitive impairment on the quarterly MDS, and received Seroquel at different doses for behavioral disturbance and manic episodes. A pharmacy recommendation stated no informed consent was found in the chart for Seroquel, and the electronic record lacked documentation that psychotropic informed consent was obtained for its use.
Inconsistent Bedtime Snack Service
Penalty
Summary
Meals and snacks were not consistently offered at bedtime in accordance with residents’ needs, preferences, and requests. During resident council, residents stated they did not receive bedtime snacks and noted they had diabetes. The Administrator stated residents should be served snacks daily, and the DON stated all residents should be offered an evening snack, especially residents with diabetes, to help maintain blood sugar levels through the night. An RN also stated snack service was inconsistent and that staff sometimes had to buy snacks for residents because the facility did not have them. Record review showed that residents with diabetes, including Residents 91, 28, 42, and 87, had diagnoses of diabetes in their medical records. Task reports showed bedtime snacks were only documented intermittently over the prior 30 days: Resident 27 received a bedtime snack 7 times, Resident 28 5 times, Resident 42 5 times, Resident 87 4 times, and Resident 91 6 times on one report and 9 times on another report. The DON provided the facility’s Food and Nutrition Services policy, which stated nourishing snacks are available 24 hours a day and may be requested as desired or scheduled between meals to accommodate typical eating patterns.
Catheter Bag Contacted Unclean Surface; Hand Hygiene Not Performed During Medication Pass
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter drainage bag for Resident 10 did not contact an unclean surface. Resident 10 had diagnoses including vascular dementia and urinary retention, and the quarterly MDS dated 9/26/25 indicated moderate cognitive impairment and an indwelling urinary catheter. The resident’s care plan, initiated on 7/9/25, included the catheter, and a physician order dated 7/16/25 directed that the catheter be changed every 30 days and as needed. On 12/9/25 and again on 12/11/25, the resident was observed lying in bed with the catheter draining bag hanging from the side of the bed and resting on the bottom leg bar of the bedside table. The Regional Nurse Consultant stated the catheter bag should not have been in contact with the bedside table leg and should not contact areas not considered clean. The facility also failed to ensure hand hygiene was performed during medication administration for four residents observed during a continuous medication pass. RN 15 prepared and administered medications to Residents 92, 93, 96, and 39 while repeatedly touching his scrub pants, wiping his forehead, mustache, and under his nose, and using hand sanitizer only once while walking in the hallway. Hand hygiene was not performed before or after medication administration for Residents 92 and 39, and was not performed after medication administration for Residents 96 and 39. The Regional Nurse Consultant stated the facility expected staff to perform hand hygiene before and after administering medication to each individual resident. The Administrator provided the facility’s medication administration policy, which stated staff follow established infection control procedures such as handwashing and antiseptic technique during medication administration.
Psychotropic Medication Documentation Deficiencies
Penalty
Summary
The facility failed to ensure psychotropic medication use was supported by required documentation for three residents reviewed for unnecessary medications. For Resident 53, the record showed major depressive disorder and use of duloxetine, with a pharmacy recommendation to consider a dose reduction from 60 mg to 40 mg at bedtime. The recommendation was marked declined, and a handwritten note from the psychologist stated the resident was actively depressed and hurting and recommended increasing duloxetine to 90 mg at bedtime. A physician order later increased the dose to 90 mg, but the pharmacy recommendation lacked the attending physician’s signature and date of review. For Resident 11, the record showed bipolar disorder and use of quetiapine. A pharmacy recommendation indicated the resident was due for a trial dose reduction of Seroquel 100 mg at bedtime, and the physician signed and dated the recommendation after it was declined. A handwritten note from the psychologist stated the resident’s mood was not great and recommended increasing Seroquel to 150 mg at bedtime, and a physician order was entered for 150 mg nightly. However, the MAR showed the resident was monitored every shift for behaviors such as depression, withdrawal, insomnia, refusal of care, and falsely accusing staff, with no behaviors documented on each shift. The record also lacked psychologist visit notes from 3/27/25 to 10/2/25 or other documentation of behavior concerns, and the Regional Nurse Consultant stated no further documentation could be provided to justify the increase. For Resident 10, the record showed insomnia and mania, with orders for trazodone at bedtime and divalproex sodium for mania. A pharmacist requested a gradual dose reduction of divalproex from 500 mg twice daily to 375 mg twice daily, but the psychologist wrote not to reduce the medication and a nurse documented the decline per the physician as recommended by the psychologist; the physician did not document a rationale or sign the form. The MARs for November and December 2025 showed every-shift behavior monitoring for aggression, agitation, mania, anxiety, resisting care, refusing care, and sleeplessness, with no behaviors documented. A behavior meeting and progress note indicated divalproex was increased to 500 mg three times daily for mania, but neither document included why the medication was increased or what behaviors were exhibited.
Failure to Provide Transfer Notice and Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a notice of transfer or discharge and bed hold policy was provided to a resident who was transferred to the hospital. Resident 12 was cognitively intact per a significant change MDS assessment dated 9/3/25. On 10/6/25, the resident was found sitting on the floor in his room, denied pain, and was assisted back to a chair. Later that day, the resident complained of right hip pain, an x-ray was ordered, and the facility received the x-ray results and obtained an order to send the resident to the ER for treatment of a fractured right hip related to the fall. The resident left by ambulance that night and returned to the facility on 10/10/25. Progress notes and the electronic record lacked documentation that a notice of transfer or discharge and a bed hold policy were provided when the resident was transferred to the hospital. During interview, the Regional Nurse Consultant stated that when a resident is transferred to the hospital, a packet should be sent with the resident that includes the notice of transfer or discharge and the bed hold policy. The consultant also provided the facility's policy titled, Transfer or Discharge, Emergency Acute Care, which stated that residents transferred to an acute care setting for emergency treatment are provided with a notice of transfer and are permitted to return to the facility.
Inaccurate PASRR Screening for Resident With Psychosis Diagnosis
Penalty
Summary
The facility failed to ensure that a PASRR Level I screening was completed accurately for one resident with diagnoses that included unspecified dementia with behavioral disturbance and unspecified psychosis. The resident’s record showed admission to the facility and a Notice of PASRR Level I Screen Outcome dated 12/14/24 stating that no Level II PASRR assessment was required because no serious mental illness was found on the Level I screening. The attached PASRR assessment did not document the resident’s psychosis diagnosis. A comprehensive MDS assessment dated 9/42/25 indicated the resident was not considered by the state to be a Level II PASRR, but did have a diagnosis of psychotic disorder other than schizophrenia. During interview, the Social Services Director stated she was not sure why the psychosis diagnosis was not included on the resident’s Level I PASRR. The facility’s PASRR Completion Policy stated that all admissions must have the appropriate PASRR completed and that if a referral indicates anything that might constitute serious mental illness or intellectual disability, the PASRR must be completed prior to admission.
Failure to Provide and Document ADL Hygiene Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided to maintain good hygiene for three residents reviewed for ADLs. Resident 10 was observed on two occasions lying in bed with untrimmed facial hair and long fingernails with dark debris underneath them. The resident’s MDS indicated moderate cognitive impairment, substantial to maximal assistance was needed for personal hygiene, and the care plan identified a need for staff assistance with ADLs related to impaired cognition and poor activity endurance. Records showed showers were provided on several dates, but the documentation lacked evidence that shaving or nail care was offered or refused, and the Regional Nurse Consultant stated these services should have been provided with showers and as needed. Resident 2 was observed with untrimmed facial hair growth and stated he wanted to keep a mustache but wanted the rest of his facial hair shaved every day or at least every other day. He reported he had not been shaved for several days. His MDS indicated he was cognitively intact with a diagnosis of unspecified dementia and no behaviors including rejection of care. The care plan indicated he required assistance with ADLs, but progress notes and shower records lacked documentation that shaving was offered or refused with showers. The Regional Nurse Consultant stated shaving should have been provided with showers and as needed, and the facility’s shaving policy required documentation of the procedure and any refusal. Resident 90 was observed with brown debris caked under her fingernails and later still had caked-on debris under her nails. Her MDS indicated limited cognition and dependence for upper body assistance and showers, and her care plan directed staff to assist with ADLs, including bathing twice weekly and as needed. Shower records showed four showers in November and none from early December through the date of review. Interviews with a CNA and RN indicated residents should receive nail cleaning on shower days, and the DON provided the facility’s nail care policy stating nail care includes daily cleaning and regular trimming.
Failure to Implement Agreed Pharmacy Lab Monitoring Recommendation
Penalty
Summary
The facility failed to ensure a pharmacy recommendation was implemented for Resident 47, who had diagnoses including manic episode, depression, and vascular dementia. A quarterly MDS dated 9/23/25 indicated the resident had severe cognitive impairment and received antipsychotic and diuretic medication during the look-back period. A pharmacy recommendation dated 6/24/25 stated the resident was receiving medications that required routine laboratory monitoring and requested CBC, Vitamin D, and CMP now and every 6 months, or alternatively TSH, LFTs, A1C, and Lipid Panel now and every 6 months, or Ferritin and Total Iron now and every 6 months. The physician marked the form as agree and signed it on 7/3/25. The electronic health record did not contain documentation that the recommended labs were drawn and did not contain a physician order for repeat labs in 6 months. During interview, the Regional Nurse Consultant stated she was unable to find documentation that the labs had been drawn as recommended and agreed upon by the physician, and confirmed there was no order to repeat the labs in 6 months. The facility did not follow the pharmacy recommendation that the physician had agreed to.
Expired Medications Found in Storage and Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from storage in accordance with medication storage requirements. In the rehab unit medication storage room refrigerator, an opened Humalog insulin pen labeled for Resident 23 had an open date of 10/5/25 and a use-by date of 11/3/25, and an opened Lantus insulin pen labeled for Resident 23 had an open date of 11/2/25 and a use-by date of 12/2/25. During interview, the Regional Nurse Consultant stated she was not aware of who or why the insulin pens were placed in the refrigerator and acknowledged that both pens were expired and should have been disposed of properly. Resident 23’s record showed a diagnosis of type II diabetes mellitus and physician orders for Humalog and later Lantus insulin. The facility also failed to remove an expired irrigation solution from an insulin medication cart. The ICF insulin medication cart contained an opened bottle of sodium chloride irrigation solution labeled for Resident 10 with an open date of 10/31/25. The Regional Nurse Consultant stated the irrigation solution was expired and should have been disposed of, noting it was good for 30 days once opened. Resident 10’s record showed diagnoses including obstructive and reflux uropathy and a physician order for sodium chloride irrigation solution 0.9% to irrigate a Foley catheter every shift.
Failure to Respond to Resident's Acute Pain and Requests for Hospital Transfer
Penalty
Summary
A resident who was cognitively intact and dependent on staff for mobility and toileting experienced acute pain and repeatedly requested to be sent to the hospital. Over the course of the night and morning shifts, multiple staff members, including CNAs and a housekeeper, observed the resident in distress and reported his condition and requests for help to nursing staff. Despite these repeated reports, the LPN on the night shift and the RN on the morning shift failed to adequately assess the resident, provide timely interventions, or notify a physician of the resident's change in condition. The resident's pain and requests for hospital transfer were dismissed or ignored, with staff making comments that minimized the resident's complaints. The resident's medical record indicated a history of constipation, with a recent KUB scan confirming constipation and ineffective results from prescribed stool softeners and laxatives. The resident had not had a bowel movement for several days, and there was no documentation of new interventions following the scan results. On the morning in question, the resident was observed screaming in pain, and his family member, after being on the phone with him for over 45 minutes, called the facility directly to demand that he be sent to the hospital. Only after this intervention from the family and notification to facility management was the resident transferred to the hospital, where he required operative intervention for a severe fecal impaction and was diagnosed with gallbladder cancer. Interviews with staff revealed that the resident's pain and requests for help were widely known throughout the facility, yet the nurses responsible did not take appropriate action. The LPN did not assess vital signs or notify the physician, and the RN delayed seeing the resident, prioritizing medication pass and expressing frustration at the resident's repeated calls for help. The lack of timely assessment and intervention resulted in prolonged pain and delayed treatment for the resident.
Failure to Timely Monitor and Treat Constipation Leading to Severe Fecal Impaction
Penalty
Summary
The facility failed to provide timely monitoring and treatment for a resident with a history of constipation who had not had a bowel movement for several days and was experiencing pain. Despite the resident's repeated complaints of pain and lack of bowel movements, staff did not perform adequate assessments, did not notify the physician of the resident's change in condition, and did not document interventions or their effectiveness. The resident received PRN medications for constipation that were documented as ineffective, but no further action was taken, and the resident's pain continued to escalate without appropriate response from nursing staff. Multiple staff members, including CNAs and nurses, were made aware of the resident's ongoing pain and requests for help, but failed to conduct timely assessments or escalate care. The resident's family ultimately intervened after hearing the resident in distress, leading to the resident being sent to the hospital, where a severe fecal impaction was discovered, requiring operative intervention under anesthesia. The medical record lacked documentation of physical assessments, physician notifications, and timely interventions in response to the resident's symptoms and ineffective medications. Additionally, the facility failed to implement an effective protocol for ongoing monitoring of bowel management for multiple residents. Reviews of other residents' records revealed delays in administering interventions for constipation, lack of timely assessments, and inconsistent documentation of bowel movements and physician notifications. The facility's bowel management program was not consistently followed, resulting in delayed care and potential harm to residents with constipation or at risk for bowel irregularity.
Removal Plan
- Reviewed and revised a new bowel procedure/protocol in collaboration with the Medical Director.
- Educated all nursing staff on the new policy.
- Implemented the new protocol.
- Conducted a complete audit of residents' records for the need and/or continued use of Milk of Magnesia (M.O.M.) and other bowel management medications.
- Confirmed orders with the Medical Director.
- Established a process where if a resident flagged on the EMAR dashboard as not having had a BM after 72 hours, they should receive a dose of MOM.
- Required that if a resident had not had a BM by the end of that nurse's shift, the physician would be notified and report given to the oncoming nurse.
- Ensured systemic plan for education and monitoring of staff to ensure staff assessed and monitored residents for pain and change in condition, and that staff followed the facility bowel protocol.
Failure to Ensure Safe Mechanical Lift Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure residents were properly assessed for and safely transferred using mechanical lifts, resulting in actual harm to a resident who fell from a mechanical lift sling and sustained a right tibia fracture. The resident, who had cerebral palsy and severe cognitive impairment, was dependent on staff for transfers and had a history of falls. During a transfer, the resident became restless and slid out of a mechanical lift sling that was not appropriately sized or compatible with the lift, as staff were not trained on sling selection or sizing. The medical record lacked documentation of a mechanical lift assessment for the resident, and staff interviews revealed confusion about sling types and sizing, with slings being ordered based solely on weight and not in accordance with manufacturer recommendations. Another resident was transferred using a mechanical lift without a physician's order or care plan documentation for mechanical lift use. During observation, staff failed to lock the wheelchair and the mechanical lift brakes during the transfer, and the sling was not properly positioned, with the pad extending several inches above the resident's head. These actions demonstrated a lack of adherence to safe transfer procedures and mechanical lift manufacturer guidelines. A third resident with a history of multiple falls did not have new preventive interventions implemented after each fall, despite repeated incidents and high fall risk scores. The care plan was not updated with new interventions following each fall, contrary to facility policy. Additionally, review of employee files showed a lack of documented competency evaluations for mechanical lift use among recently hired staff. These deficiencies contributed to unsafe conditions and inadequate supervision to prevent accidents.
Failure to Ensure Staff Competency in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in performing mechanical lift transfers, as evidenced by multiple observed incidents involving two residents who required such transfers. In one case, a resident with severe cognitive impairment, cerebral palsy, and a recent major injury was transferred using a mechanical lift by two CNAs. During the transfer, the resident became restless and maneuvered herself out of the sling, resulting in a fall and a right tibia fracture. Staff interviews and documentation revealed that the CNAs were not adequately trained on selecting the correct sling type or size, and there was confusion regarding the compatibility of slings with the mechanical lift equipment. The slings used were sometimes not appropriate for the resident's needs, and staff were unclear on how to support the resident's fractured leg during transfers. In another observed incident, a resident was transferred from a wheelchair to a bed using a mechanical lift. During this process, the CNA failed to lock the wheelchair and the mechanical lift prior to transferring and lowering the resident, respectively. Additionally, the staff involved were unable to determine the correct size of the lift pad for the resident, and there was no physician order documented for the use of a mechanical lift for this resident. Observations also noted that some mechanical lift slings were not labeled with resident names, and staff reported using slings that were not always the correct size or type due to lack of training or availability. Interviews with various staff members, including CNAs and QMAs, confirmed a lack of knowledge and training regarding the selection and use of mechanical lift slings, as well as the proper procedures for safe transfers. Staff were not consistently aware of manufacturer guidelines, facility policies, or the specific needs of residents during mechanical lift transfers. These deficiencies in staff competency and adherence to policy had the potential to affect all residents requiring mechanical lift transfers in the facility.
Delayed Family Notification of Resident Fracture
Penalty
Summary
A resident with cerebral palsy and severe cognitive impairment experienced a fall during a mechanical lift transfer, resulting in the resident sliding out of the lift sling and landing on her right side. The incident was witnessed by two CNAs, and the resident was assessed by a nurse and a nurse practitioner, who determined she could be moved and later assisted her to lunch. The resident's family member was notified of the initial incident. Subsequently, x-rays were ordered and completed, revealing a right tibia fracture. The physician was notified, and appropriate medical interventions were initiated, including a splint and an orthopedic referral. Despite the discovery of the fracture, there was no documentation that the resident's Power of Attorney (POA) or family member was notified of the new injury on the day it was identified. The record shows that the POA was not informed of the fracture until the following day, contrary to facility policy requiring timely notification of a resident's representative in the event of an injury or significant change in condition. The delay in notification was confirmed during an interview with the DON, who discovered the lapse during a morning meeting and subsequently ensured the family was informed.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, as observed during a survey. Resident B was found with long, jagged nails containing dark debris, despite having a care plan that required daily ADL assistance. Resident E, who was cognitively intact but required extensive assistance, was observed with multiple chin hairs, indicating a lack of personal hygiene care. Similarly, Residents F and G, both with severe cognitive impairments, were also observed with multiple chin hairs, suggesting a failure in providing necessary grooming assistance. Resident D's care was also found lacking, as the facility failed to provide the preferred number of showers. Despite a care plan indicating a preference for showers twice a week, documentation showed Resident D received only three showers over a 30-day period. This discrepancy was highlighted by a grievance from Resident D's family, expressing concerns about the adequacy of his showers and personal hygiene. Interviews with staff revealed inconsistencies in the documentation and execution of shower schedules, with the Director of Nursing unaware of any complaints regarding shower preferences. The facility's policy on ADL care, which includes personal hygiene tasks such as shaving and nail care, was not adhered to, as evidenced by the observations and interviews. The Director of Nursing confirmed that residents should be shaved and have their nails cut on shower days, yet this was not consistently practiced. The lack of proper documentation and adherence to care plans contributed to the deficiencies observed in the care provided to the residents.
Failure to Notify Resident's Representative of Changes in Condition
Penalty
Summary
The facility failed to notify a resident's representative of changes in condition and treatment for Resident B, who was on hospice services. The Power of Attorney (POA) for Resident B was not informed of several significant changes, including an incident between Resident B and another resident, a transfer to a psychiatric facility, medication changes, and the resident being placed in isolation. The hospice agency was also not informed of the transfer order. Resident B's medical record indicated multiple instances where the POA was not notified of changes in condition or treatment. These included a chest x-ray and subsequent antibiotic administration, a change in condition requiring intravenous fluids, and a transfer to the hospital emergency room for evaluation and treatment. The facility's policy required notification of the resident's representative in such cases, but documentation of these notifications was lacking. Interviews with facility staff, including a Qualified Medication Aide, a Registered Nurse, and the Director of Nursing, revealed that the standard procedure was to notify the family or responsible party of changes in condition. However, the documentation did not reflect that these notifications were made. The facility's policy documents, provided by the Director of Nursing, outlined the requirement for notifying the resident's representative of significant changes, but these procedures were not followed in the case of Resident B.
Failure to Provide Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure that transfer and discharge documents were completed and provided to a resident's representative for a discharge to the hospital. This deficiency was identified for a resident with vascular dementia, who was involved in an incident where they exhibited socially inappropriate behavior towards another resident. Following this incident, the resident was referred to a Behavioral Health Care (BHC) hospital, but the facility did not have documentation of a physician's order for this transfer. Additionally, the facility's records lacked the necessary transfer and discharge forms that should have been completed and provided to the resident's representative. During an interview, a Regional Clinical Consultant confirmed that the facility was unable to locate these documents, which were required to be completed and included in the resident's medical record. The facility's policy indicated that notice should be given to the resident or responsible party before a transfer to a hospital, but this procedure was not followed in this case.
Failure to Provide Bed Hold Documentation for Hospital Transfer
Penalty
Summary
The facility failed to ensure that bed hold documents were completed and provided to a resident's representative during a transfer to a hospital. This deficiency was identified for a resident diagnosed with vascular dementia, who was transferred to a Behavioral Health Care (BHC) hospital following an incident involving inappropriate behavior. The resident's record lacked documentation of a bed hold policy being completed and provided to the resident's representative, which is a requirement prior to hospital transfer. During the review, it was noted that the facility was unable to locate the completed bed hold policy documents for the resident's transfer. The facility's policy mandates that information regarding the resident's bed status and how the bed will be held should be provided to the resident or their representative, and a copy should be placed in the resident's medical record. However, this was not done, as confirmed by the Regional Clinical Consultant during an interview.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct timely care plan meetings for two residents, leading to a deficiency in care planning. Resident 44, who has multiple sclerosis and adult failure to thrive, had not had a care plan meeting since February, despite a quarterly MDS assessment in July indicating a moderate cognitive deficit. The Social Services Director (SSD) was unaware of the missed meeting and did not document the reasons for the absence of the resident and her representative. A planned meeting in August was not held because the resident and family did not plan to attend, and the SSD did not know that meetings could proceed without them. Similarly, Resident 76, with a history of cerebral infarction and no cognitive deficit, had not had a care plan meeting since June. The SSD, new to her position, was unaware of this lapse and had planned a meeting for September, but had not received confirmation from the resident or family. The SSD did not document the resident's decision to decline attendance and was unaware that meetings could occur without the resident or representative. The facility's policy requires documentation of notifications and attendance, which was not followed in these cases.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper handling of a resident's indwelling urinary catheter bag, which was observed lying flat on the floor, exposing it to potential infection risks. This deficiency was noted during a random observation of a resident who had an active urinary tract infection (UTI) and was receiving antibiotic treatment. The facility's policy, as indicated by the Regional Clinical Consultant, mandates that catheter tubing and drainage bags should not come into contact with the floor to prevent infection control risks. Additionally, the facility failed to maintain accurate documentation of urine output for two residents with indwelling urinary catheters. Significant discrepancies were found between the Point of Care (POC) task forms completed by Certified Nursing Assistants (CNAs) and the Treatment Administration Records (TARs). These discrepancies in recorded urine output amounts could potentially impact the residents' care, as accurate measurement is crucial for monitoring their condition and preventing complications. Interviews with facility staff revealed a lack of clear communication and documentation procedures regarding urine output measurements. CNAs were responsible for emptying catheter drainage bags and relaying the information to nurses, but inconsistencies in documentation locations within the computer system contributed to the discrepancies. The facility's policy emphasized the need for accurate measurement of urinary output and ongoing monitoring of catheter-related issues, highlighting the importance of adherence to these protocols to prevent UTIs and ensure proper resident care.
Improper Labeling of Tube Feeding Formula
Penalty
Summary
The facility failed to ensure proper labeling and dating of an opened bottle of tube feeding formula for a resident with a feeding tube. During an observation, two bottles of Glucerna formula were found on the bedside table of a resident with severe cognitive impairment and multiple medical conditions, including dysphagia and obstructive hydrocephalus. One bottle was full, and the other was partially used, but neither was labeled or dated. An LPN admitted to using the partially empty bottle for the resident's bolus feeding without knowing when it was opened, which violated the facility's policy requiring opened formulas to be labeled with the date, expiration, and initials. Further observations revealed another bottle of Glucerna on the resident's bedside table, which was labeled with the date and initials but lacked the time it was opened. The Director of Nursing confirmed that the bottle should have included the time of opening, as the formula is only good for a specified period after being opened. The facility's policy on enteral tube feeding and the specific instructions for using Glucerna 1.2 Cal were not followed, increasing the potential for microbial contamination due to improper handling and labeling of the feeding formula.
Failure to Address Pharmacy Recommendation for Dose Reduction
Penalty
Summary
The facility failed to address a pharmacy recommendation for a resident regarding the administration of Zoloft (sertraline) for depression. The resident, who had diagnoses including depressive episodes, insomnia, cognitive communication deficit, disorientation, and hallucinations, was on a daily dose of 50 mg of Zoloft. A pharmacy review conducted by Pharmacy Management Solutions recommended a dose reduction to 25 mg and requested documentation of the resident's current mental and behavior status, or a detailed reason for not reducing the dose. However, there was no documentation of a response from the provider to this recommendation. Interviews with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) revealed that the pharmacy review had not been addressed, and neither could provide an explanation or additional documentation indicating that the recommendation was acted upon. The facility's policy required that any recommendations from the consultant pharmacist be reported to the attending physician, DON, and medical director, and that each recommendation must be acted upon. The lack of response to the pharmacy's recommendation constituted a failure to comply with this policy.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards during kitchen operations. During a kitchen tour, it was observed that a staff member was preparing food without covering his mustache with a hair restraint, which is against the facility's policy. This was noted on two separate occasions, and the Dietary Manager (DM) acknowledged that facial hair should be covered. Additionally, the facility's policy on personal appearance mandates the use of hairnets, hair restraints, and beard guards, which was not followed in this instance. Furthermore, the facility did not ensure proper storage of potentially hazardous foods. In the walk-in refrigerator, raw beef and pork were found thawing together in a pan, with cooked beef stored on the same shelf, contrary to the facility's food storage policy. The DM confirmed that raw and cooked meats should not be stored together. Additionally, expired food items, such as loaves of bread, were found in various pantries, which should have been discarded according to the facility's date marking policy. The DM indicated that the night dietary aides were responsible for monitoring expiration dates, but this was not effectively carried out.
Improper Maintenance and Documentation of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper maintenance and documentation of respiratory equipment for eight residents requiring respiratory care. Observations revealed that oxygen tubing and nebulizer equipment were not consistently dated, bagged, or stored appropriately. For instance, Resident J's oxygen tubing was dated three months prior, and Resident K's oxygen tubing lacked a date, with an empty humidity bottle attached to the concentrator dated several months earlier. Additionally, Resident H's nebulizer treatment set was unbagged, and Resident C's oxygen equipment was undated and improperly stored. Further observations indicated that some residents, such as Residents D, E, and F, had oxygen tubing lying unbagged on the floor, with no orders for oxygen administration documented in their medical records. Resident G's equipment storage bags were dated but lacked corresponding orders for oxygen administration. Interviews with facility staff, including a Qualified Medication Aide and the Assistant Director of Nursing, confirmed that oxygen equipment should be dated and bagged, with changes occurring weekly. However, the facility's policy on oxygen administration was undated, and the staff failed to adhere to the policy's requirements for labeling and maintaining respiratory equipment.
Failure to Provide Alternative Hydration Choices
Penalty
Summary
The facility failed to ensure that residents had access to alternative hydration choices for two out of the three days of the survey, affecting all 81 residents who received hydration from the kitchen. On one occasion, a Certified Nursing Aide (CNA) reported that the Dietary Manager (DM) instructed staff not to make coffee for residents on the units because it needed to be temperature-checked before serving. This decision led to the removal of coffee grounds from the units, preventing residents from having coffee when they desired, particularly in the mornings before the kitchen opened at 7 a.m. The lack of available drinks in the units' pantries was confirmed during an observation, where no drinks were found in the refrigerators, and coffee supplies were absent. The Dietary Manager explained that drinks, including coffee, were served when the kitchen opened, and the Director of Nursing (DON) had removed coffee from the units due to temperature concerns. Although individual containers of orange juice were purchased for the pantries, they were served during breakfast instead. The facility's policy on hydration management, provided by the Regional Nurse Consultant, outlined that fluids should be offered at various times, including mid-morning, mid-afternoon, and at bedtime, in addition to mealtimes and during medication administration. However, this policy was not adhered to, as staff only provided ice water and did not offer other drinks like coffee, which residents preferred.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for Resident AA, who was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and congestive heart failure. The resident had a physician's order for Sitagliptin-metformin HCL (Janumet) to be administered twice daily for diabetes management. However, the Medication Administration Record (MAR) indicated that the resident did not receive the prescribed medication on multiple occasions, specifically on 6/29/24, 6/30/24, 7/1/24, 7/2/24, and the morning dose on 7/3/24. The medical record lacked documentation of physician notification regarding these missed doses. Interviews with facility staff, including an LPN, an RN, and the Director of Nursing (DON), revealed that the standard procedure for unavailable medications involved checking the emergency drug supply and contacting the pharmacy for immediate delivery if necessary. Despite these protocols, the facility did not follow through with obtaining the medication or notifying the physician of the missed doses. The facility's policy on medication shortages outlined steps to be taken in such situations, but these were not adhered to, resulting in the deficiency noted in the report.
Failure to Report Allegations of Abuse and Incomplete Investigation Documentation
Penalty
Summary
The facility failed to ensure a resident's allegation of abuse and investigation of bruising were accurately reported. Resident B was found with bruising on bilateral arms, face, and chest, and a laceration on the lip. The initial report indicated the resident had swelling and bruising on her left hand and right arm, but the source of the bruising was not identified. An X-ray was ordered, and the resident was referred to social services. The investigation was completed without findings, and the resident's care plan was updated to reflect combative behavior with care. However, the follow-up report lacked detailed documentation of the extent of the bruising and the laceration on the lip, and it did not include the suspension of CNA 9 for five days pending the investigation. Witness statements revealed that on the day of the incident, the resident was heard screaming, and upon investigation, was found with bruising. The resident alleged that CNA 9 was trying to rape her, and the CNA was suspended for five days. However, the allegations of abuse were not reported to the state authorities. The ADM indicated that the extensive bruising and laceration were possibly caused by the resident being resistant to care and flailing her arms. The ADM also mentioned that the allegations of abuse were not reported because the resident had a history of PTSD from being raped. The facility's Abuse Prevention Policy requires employees to report any incident, allegation, or suspicion of abuse to the Administrator, who will then report it to the state authorities. The policy also mandates that all incidents be documented, and a final investigation report be completed within the required time frame. However, in this case, the facility failed to follow its policy, as the allegations of abuse were not reported, and the final report lacked detailed documentation and did not include the suspension of CNA 9.
Failure to Document and Follow Up on Falls, Injuries, and Abuse Allegations
Penalty
Summary
The facility failed to have a system in place for documentation of falls, non-pressure wounds, and injuries, and failed to ensure assessments and documentation were completed after falls, non-pressure wounds, and allegations of abuse were identified for three residents. Resident B was found with multiple bruises and a laceration on her lip, but the facility did not document the immediate follow-up treatment, root cause of the bruising, or notify the resident representative. Additionally, the care plan was not updated to reflect the resident's combative behavior, and there was no documentation of psychosocial support provided for seven days as ordered. Witness statements and interviews revealed inconsistencies and lack of proper documentation regarding the resident's injuries and the alleged abuse incident involving a CNA. Resident C had a history of falls and was found on the floor on multiple occasions. However, the facility failed to document 72-hour post-fall follow-up, notify the family representative at the time of the incidents, or complete a skin assessment for a bruise on the left hip. The resident's care plan included interventions for fall risk, but the documentation was incomplete and lacked follow-up on the resident's condition after the falls. Resident D reported being hit by a night shift CNA, but the facility's documentation lacked follow-up on the resident's allegations of abuse, psychosocial support for seven days, and updates to the care plan to reflect false allegations and racial slurs. The resident's record also lacked documentation of skin impairments found during the investigation. Interviews with staff indicated that the facility's process for assessing and documenting injuries, falls, and abuse allegations was not consistently followed, leading to incomplete and inadequate documentation of the residents' conditions and care.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 33 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Covington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Williamsport Nursing And Rehabilitation | 11.6 mi | ★★★★★ | 0 | 0 |
| La Bella Of Danville | 12.1 mi | ★★★★★ | 16 | 3 |
| Hawthorne Inn Of Danville | 13.1 mi | ★★★★★ | 2 | 0 |
| Accolade Healthcare Danville | 14.2 mi | ★★★★★ | 7 | 0 |
| Goldwater Care Danville | 14.8 mi | ★★★★★ | 8 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.